后顱窩減壓及硬膜成形術與單純后顱窩減壓術比較治療Ⅰ型Chiari畸形效果的Meta分析_《中國循證醫學雜志》

作者：

張豆豆 , 陳海鋒 ,  黃思慶 , 郝德 , 任海波 , 湯俊佳

四川大學華西醫院神經外科（成都 610041）;

關鍵詞：

Ⅰ型Chiari畸形硬膜成形術 Meta 分析系統評價隊列研究

DOI：

10.7507/1672-2531.20120170

視頻：

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目的　系統評價后顱窩減壓及硬膜成形術（PFDD）與單純后顱窩減壓（PFD）兩種術式比較治療Ⅰ型Chiari 畸形的有效性和安全性。
方法　計算機檢索CENTRAL、Science Citation Index Expanded、MEDLINE（Ovid）、PubMed、CBM、CNKI和WanFang Data，收集比較后顱窩減壓及硬膜成形術（PFDD）與單純后顱窩減壓（PFD）治療Ⅰ型Chiari 畸形有效性和安全性的文獻，并輔以檢索納入研究的參考文獻。檢索時限均從1993年至2011年9月。由2位評價者按照納入和排除標準獨立選擇文獻，提取資料，采用 Newcastle-Ottawa量表對納入研究進行方法學質量評價，然后采用 RevMan 5.1軟件對數據進行 Meta 分析，并采用 GRADE 系統評價證據質量評價。
結果　共納入10個隊列研究，829例患者。Meta 分析結果顯示：① PFDD組再手術率低于PFD組［RR=0.41，95%CI（0.23，0.74），P=0.003］，PFDD組術后脊髓空洞縮小率高于PFD組［RR=1.27，95%CI（1.03，1.56），P=0.02］，術后臨床癥狀改善兩組差異無統計學意義［RR=1.11，95%CI（0.95，1.28），P=0.18］。② PFDD組術后腦脊液相關并發癥發生率顯著高于PDF組［RR=6.3，95%CI（2.71，14.67），P lt;0.000 1］，而術后枕部疼痛及傷口感染發生率兩組差異均無統計學意義（P gt;0.05）。基于上述系統評價結果，采用 GRADE 系統評價證據質量及推薦等級，證據總體質量評級為低質量，推薦強度為弱推薦。
結論　與PFD相比，PFDD可減少再次手術率，提高脊髓空洞縮小率，但會顯著增加腦脊液相關并發癥發生的風險。受納入研究質量較低等因素影響，上述結論尚需更多高質量、大樣本的RCT 進一步加以驗證。我們建議臨床上根據患者情況，個性化選擇使用。

引用本文： 張豆豆,陳海鋒,黃思慶,郝德,任海波,湯俊佳. 后顱窩減壓及硬膜成形術與單純后顱窩減壓術比較治療Ⅰ型Chiari畸形效果的Meta分析. 中國循證醫學雜志, 2012, 12(9): 1090-1097. doi: 10.7507/1672-2531.20120170 復制

1.	Tubbs RS, Lyerly MJ, Loukas M, et al. The pediatric Chiari I malformation: a review. Childs Nerv Syst, 2007, 23(11): 1239-1250.
2.	Mortazavi MM, Tubbs RS, Hankinson TC, et al. The first posterior fossa decompression for Chiari malformation: the contributions of Cornelis Joachimus van Houweninge Graftdijk and a review of the infancy of “Chiari decompression”. Childs Nerv Syst, 2011, 27(11): 1851-1856.
3.	Wells G, Shea B, O’connell D, et al. The Newcastle-Ottawa Scale NOS for assessing the quality of nonrandomized studies in meta-analyses. Ottawa, Canada: Dept of Epidemiology and Community Medicine, University of Ottawa. http: // www.ohri.ca/programs /clinical_epidemiology /oxford.htm.
4.	Munshi I, Frim D, Stine-Reyes R, et al. Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery, 2000, 46(6): 1384-1390.
5.	Limonadi FM, Selden NR. Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome. J Neurosurg, 2004, 101(2 Supp l): 184-188.
6.	Navarro R, Olavarria G, Seshadri R, et al. Surgical results of posterior fossa decompression for patients with Chiari I malformation. Childs Nerv Syst, 2004, 20(5): 349-356.
7.	Yeh DD, Koch B, Crone KR. Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation type I. J Neurosurg, 2006, 105(1 Supp l): 26-32.
8.	McGirt MJ, Attenello FJ, Datoo G, et al. Intraoperative ultrasonography as a guide to patient selection for duraplasty after suboccipital decompression in children with Chiari malformation Type I. J Neurosurg Pediatr, 2008, 2(1): 52-57.
9.	張斌, 沈冰. 不同術式對Arnold-Chiari畸形并脊髓空洞的療效分析. 寧夏醫學雜志, 2009, 31(4): 333-334.
10.	Mutchnick IS, Janjua RM, Moeller K, et al. Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr, 2010, 5(5): 474-478.
11.	Romero FR, Pereira CA. Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation? Arq Neuropsiquiatr, 2010, 68(4): 623-626.
12.	劉彬, 王振宇, 李振東, 等. 不同手術方式治療 Chiari 畸形合并脊髓空洞的臨床研究.中華神經醫學雜志, 2005, 4 (11) : 1137-1139.
13.	Yilmaz A, Kanat A, Musluman AM, et al. When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale? World Neurosurg, 2011, 75(2): 307-313.
14.	Guyatt GH, Oxman AD, Akl E, et al. GRADE Guidelines: 1. Introduction to GRADE Evidence Proiles and Summary of Findings Tables. J Clin Epidemiol, 2011, 64(4): 383-943.
15.	Sackett DL, Straus SE, Ricbardson WS, et al. Evidence-based Medicine: how to practice and teach EBM. 2nd edition. Churchill Livingstone,London. 2000: 173-175.
16.	Weiner SJ. Contextualizing medical decisions to individualize care: lessons from the qualitative sciences. J Gen Intern Med, 2004, 19(3): 281-285.
17.	Schulz KF, Moher D, Altman DG. CONSORT 2010 comments. Lancet, 2010, 376(9748): 1222-1223.

1. Tubbs RS, Lyerly MJ, Loukas M, et al. The pediatric Chiari I malformation: a review. Childs Nerv Syst, 2007, 23(11): 1239-1250.
2. Mortazavi MM, Tubbs RS, Hankinson TC, et al. The first posterior fossa decompression for Chiari malformation: the contributions of Cornelis Joachimus van Houweninge Graftdijk and a review of the infancy of “Chiari decompression”. Childs Nerv Syst, 2011, 27(11): 1851-1856.
3. Wells G, Shea B, O’connell D, et al. The Newcastle-Ottawa Scale NOS for assessing the quality of nonrandomized studies in meta-analyses. Ottawa, Canada: Dept of Epidemiology and Community Medicine, University of Ottawa. http: // www.ohri.ca/programs /clinical_epidemiology /oxford.htm.
4. Munshi I, Frim D, Stine-Reyes R, et al. Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery, 2000, 46(6): 1384-1390.
5. Limonadi FM, Selden NR. Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome. J Neurosurg, 2004, 101(2 Supp l): 184-188.
6. Navarro R, Olavarria G, Seshadri R, et al. Surgical results of posterior fossa decompression for patients with Chiari I malformation. Childs Nerv Syst, 2004, 20(5): 349-356.
7. Yeh DD, Koch B, Crone KR. Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation type I. J Neurosurg, 2006, 105(1 Supp l): 26-32.
8. McGirt MJ, Attenello FJ, Datoo G, et al. Intraoperative ultrasonography as a guide to patient selection for duraplasty after suboccipital decompression in children with Chiari malformation Type I. J Neurosurg Pediatr, 2008, 2(1): 52-57.
9. 張斌, 沈冰. 不同術式對Arnold-Chiari畸形并脊髓空洞的療效分析. 寧夏醫學雜志, 2009, 31(4): 333-334.
10. Mutchnick IS, Janjua RM, Moeller K, et al. Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr, 2010, 5(5): 474-478.
11. Romero FR, Pereira CA. Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation? Arq Neuropsiquiatr, 2010, 68(4): 623-626.
12. 劉彬, 王振宇, 李振東, 等. 不同手術方式治療 Chiari 畸形合并脊髓空洞的臨床研究.中華神經醫學雜志, 2005, 4 (11) : 1137-1139.
13. Yilmaz A, Kanat A, Musluman AM, et al. When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale? World Neurosurg, 2011, 75(2): 307-313.
14. Guyatt GH, Oxman AD, Akl E, et al. GRADE Guidelines: 1. Introduction to GRADE Evidence Proiles and Summary of Findings Tables. J Clin Epidemiol, 2011, 64(4): 383-943.
15. Sackett DL, Straus SE, Ricbardson WS, et al. Evidence-based Medicine: how to practice and teach EBM. 2nd edition. Churchill Livingstone,London. 2000: 173-175.
16. Weiner SJ. Contextualizing medical decisions to individualize care: lessons from the qualitative sciences. J Gen Intern Med, 2004, 19(3): 281-285.
17. Schulz KF, Moher D, Altman DG. CONSORT 2010 comments. Lancet, 2010, 376(9748): 1222-1223.

《中國循證醫學雜志》

后顱窩減壓及硬膜成形術與單純后顱窩減壓術比較治療Ⅰ型Chiari畸形效果的Meta分析

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《中國循證醫學雜志》

后顱窩減壓及硬膜成形術與單純后顱窩減壓術比較治療Ⅰ型Chiari畸形效果的Meta分析

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